Chapman’s Orthopaedic Surgery
3rd Edition

CHAPTER 72
ARTHRODESIS OF THE HAND AND WRIST
Edward Akelman
Michael T. LeGeyt
Dina Hulsizer Galvin
E. Akelman, M. T. LeGeyt, and D. H. Galvin: Department of Orthopaedics, Brown University–Rhode Island Hospital, Providence, Rhode Island, 02905.
SMALL-JOINT ARTHRODESIS IN THE HAND AND WRIST
Pain-free use of the hand is critical to independent functional and productive living. There are numerous medical conditions that limit the use of the small joints of the hand because of pain, deformity, dysfunction, and instability. Among these are trauma, infection, connective tissue disease, arthritides, osteoarthrosis, paralytic disorders, failed surgical procedures, and congenital deformities. Many medical and surgical advances have been made to improve the hand function of affected patients. One of the mainstays has been to perform arthrodeses of selected joints of the hand and wrist. Arthrodesis, or joint fusion, remains one of the most time-tested, reliable, and useful hand surgery procedures (39,62). Reasons to perform small-joint arthrodesis are to correct deformity, to relieve
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pain, to control instability, and to improve loss of function caused by neurovascular disease (9,48,55,74,89). A properly performed small-joint arthrodesis can markedly improve hand function and the overall quality of life for an afflicted patient.
INDICATIONS FOR SURGERY
FINGER METACARPOPHALANGEAL, PROXIMAL INTERPHALANGEAL, AND DISTAL INTERPHALANGEAL JOINTS
Osteoarthritis commonly affects the distal interphalangeal (DIP) joints of the fingers and, to a lesser extent, the interphalangeal (IP) joint of the thumb. Other diseases that less commonly affect the DIP joints are psoriatic arthritis, rheumatoid arthritis, and infection. In all these diseases, hand function is limited by painful motion of the joints. Arthrodesis of the DIP joint is a successful way to eliminate the pain associated with these disorders.
The proximal interphalangeal (PIP) joints are more commonly involved in rheumatoid arthritis as well as osteoarthritis. Posttraumatic arthrosis of a single PIP joint is a common problem. The disability for the rheumatoid patient is the associated swan-neck or boutonnieére deformity, while for the posttraumatic arthritic patient it is usually pain. Arthrodesis of the PIP joints is a reliable method of returning function to these fingers, and it is especially appropriate for the index and small fingers because of their unique position as border digits.
Metacarpophalangeal (MCP) joints may be affected in multiple fingers in rheumatoid arthritis, or singly in posttraumatic arthritis. Arthroplasty is usually preferred for the MCP joints of the fingers to preserve good motion and function. Arthrodesis is useful for joints when arthroplasty is not indicated, or when a previous arthroplasty has failed.
Carpometacarpal arthrodesis, although less commonly performed, can also improve functional outcomes, particularly in the fourth and fifth carpometacarpal joints, which may have osteoarthrosis as a late sequela of fracture dislocations (15,17). Elimination of pain and increased stability improves hand function.
THUMB INTERPHALANGEAL, METACARPOPHALANGEAL, AND CARPOMETACARPAL JOINTS
The thumb interphalangeal (IP) joint is not unlike the IP joints of the digits. It is important for stable power pinch, which may be compromised in osteoarthritis because of pain or connective tissue disease caused by joint laxity.
The thumb MCP joint is different from the other MCP joints in that significantly more stress is placed on the ligamentous restraints than in the finger joints. This is because of the unique position of the thumb and its role in pinch and grasp. Instability of this joint is common because of chronic laxity after a missed acute tear of the ulnar collateral ligament (gamekeeper’s thumb) and rheumatoid arthritis (19,48). While ligament reconstruction and soft-tissue procedures are usually preferred, in the arthritic thumb MCP joint, arthrodesis (Fig. 72.1, Fig. 72.2) provides a more lasting option and is generally preferred to arthroplastic techniques for a number of different disorders (36).
Figure 72.1. Thumb metacarpophalangeal joint fusion, anteroposterior view.
Figure 72.2. Metacarpophalangeal joint fusion, lateral view.
In the thumb, the joint most commonly affected with osteoarthritis is the carpometacarpal (CMC) joint (6). This is perhaps the most commonly involved joint in postmenopausal women with early osteoarthritis. It has been postulated to be secondary to laxity of the metacarpal volar beak ligament, allowing enough subluxation and incongruity of the joint to become pathologic. A second commonly affected group is young people with high demands on their hands (e.g., manual laborers) who have posttraumatic arthritis after an old intraarticular fracture of the base of the metacarpal (Bennett’s or Rolando’s fracture). Eaton et al. (28a) have classified this pattern of osteoarthrosis of the first CMC joint into four stages. Stage I has normal intraarticular cartilage with joint-space widening. In stage II, there is narrowing of the joint space but the articular contours are normal. Stage III disease has
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significant destruction of the thumb CMC joint, but the scaphotrapeziotrapezoidal (STT) joint is normal. In stage IV disease, there is destruction of the STT joint in addition to the first CMC joint. Arthrodesis of the thumb CMC joint is indicated for stage III disease but is contraindicated in the presence of any scaphotrapeziotrapezoidal disease (stage IV).
Patients who benefit most from an arthrodesis of the thumb CMC joint are usually young, active people who require a strong, stable, pain-free thumb to perform work activities (6,20). House et al. (43) found that arthrodesis of the first CMC improved hand function in patients with tetraplegia following spinal cord injury (see Chapter 68). Arthrodesis is the best salvage procedure for failed arthroplasty or previous infection of the first CMC joint. Older patients and patients whose demands for strength of pinch and grip are not high are better served with an arthroplasty (see Chapter 70). Moore et al. (72) reported successful use of arthrodesis for a rare problem, laxity of the thumb CMC joint in patients with Ehlers-Danlos syndrome. Thumb CMC arthrodesis significantly limits thumb motion, although some compensatory motion occurs at the STT and the MCP joints; therefore, in patients who require motion of the thumb, arthrodesis is contraindicated.
SURGICAL PLANNING
Surgeons differ in the choice of skin incision; the approach to the soft-tissue envelope about a joint; the manner in which the joint surfaces are prepared; whether to use bone graft or bone substitutes, or no graft; fixation methods; and postoperative management, including rehabilitation (27). The goals of arthrodesis in the small joints of the hands are uncomplicated soft-tissue and skin healing, appropriate joint position, and bony union in the shortest possible time (15). The best techniques are simple, straightforward, and reliable, and they allow early motion of the remainder of the hand. Successful fusion requires a good soft-tissue envelope about the joint as well as well-vascularized bone at the fusion site. Address any deficiencies prior to undertaking a fusion.
SURGICAL TECHNIQUES
INCISIONS AND EXPOSURE OF THE JOINTS
  • Straight longitudinal incisions are the best incisions for fusions in the small joints of the hand. Use gentle curved incisions, and H, Y, V, and other types of incisions, only in good-quality, well-vascularized skin and soft tissue. Expose the thumb carpometacarpal joint through a Wagner type of anterior incision or through a dorsal incision directly over the joint (see Chapter 37).
  • Approach the DIP joints of the fingers and the IP joint of the thumb by transversely dividing the extensor mechanism and capsule. Debride the soft tissues as needed. We prefer excision of the radial and ulnar collateral ligament complexes prior to arthrodesis.
  • Remove all marginal and dorsal osteophytes.
  • Approach the digital PIP joints by dividing the extensor tendon mechanism longitudinally. Careful dissection preserves the interval between the extensor mechanism and the dorsal joint capsule. Preserve the joint capsule if possible.
  • Approach the MCP joints of the fingers by dividing the ulnar sagittal fibers. Retract the entire extensor mechanism to one side and visualize the joint capsule. Then make a direct longitudinal approach through the capsule.
  • Approach the MCP joint of the thumb by dividing the radial sagittal fibers, detaching the extensor pollicis brevis insertion, and pulling the extensor pollicis longus (EPL) ulnarly. Incise the joint capsule longitudinally and debride as indicated.
  • For the carpometacarpal joint of the thumb, make a volar anterior approach.
  • Elevate the origin of the thenar musculature from the thumb metacarpal and trapezial area.
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  • You may partially detach the thenar muscle and bone insertions of the abductor pollicis longus if necessary for exposure of the carpometacarpal joint. Pay careful attention to preserving the joint capsule for closure.
PROPER POSITIONING
A patient who has disease throughout the small joints of the hand will generally be better served with an arthroplasty of the finger MCP joints and arthrodeses of the PIP and DIP joints. The position for arthrodesis in the fingers is critical to hand function. In general, there should be a gentle cascade from radial to ulnar with more flexion of the ulnar digits, as can be appreciated in the normal hand at rest.
  • Fuse the MCP joint of the index finger in 25° to 30° of flexion, adding another 5° of flexion at each joint, moving ulnarly, to end at 40° to 45° of flexion in the small-finger MCP joint.
  • There should be no radial or ulnar deviation at the MCP joints. Ensure that there is no rotational deformity, although some have suggested that gentle supination may help with thumb-pad pinch. There should be more flexion at the PIP joints than at the MCP joints in each digit.
  • Fuse the index-finger PIP joint at 40° to 45° of flexion, with an additional 5° of flexion added at each PIP joint to end at 55° to 60° of flexion at the small-finger PIP joint.
  • The DIP joints are very important to hand function. Fusion in too much flexion is disabling and cosmetically undesirable. Our experience is that too much extension of these joints is tolerated better than too much flexion. Fuse the DIP joint at 0° to 15° of flexion.
  • The thumb position is most critical to hand function because of its unique role. Fuse the thumb MCP joint in approximately 10° flexion with no radial or ulnar deviation.
  • Fuse the thumb IP joint in a position of 0° to 15° of flexion.
  • Fuse the thumb carpometacarpal joint in 15° to 20° of extension, 45° of palmar abduction, and 5° to 10° of pronation.
  • Check the positioning of all joint arthrodeses intraoperatively by temporarily fixing the joints with Kirschner wires (K-wires) prior to permanent fixation.
PREPARATION OF BONY SURFACES
Successful arthrodesis of a small joint in the hand requires careful preparation of the bone surfaces of the joint (15,48). Excellent cancellous-to-cancellous bone contact gives the best chance for fusion.
Convex–Concave Technique
The convex–concave surgical technique is generally accepted as the most straightforward method (15).
  • Remove the articular cartilage and subchondral bone using a small curet or rongeur and expose the subchondral cancellous bone.
This allows maintenance of the normal contour of the joint; therefore, minimal shortening is required and positioning is easy in flexion/extension, radial/ulnar deviation, and rotation.
Cup and Cone Preparation
The cup and cone technique can be used with all fixation systems. It is considered advantageous because it presents large, opposing cancellous surfaces for fusion (19,66), but it does increase digital shortening. Recently, cup and cone reamers have been made available commercially that provide matching surfaces in the joint. This method is generally used more commonly at the MCP joints. The CMC joint of the thumb can be fused using this method, with the cone being made from the first metacarpal base and the cup being fashioned in the trapezium. Carroll (16) has shown excellent results.
CUTS
Transverse
Transverse cuts preserve digital length and are commonly used (19). Although precise transverse or straight cuts are difficult to achieve, this is our preferred method, and it provides excellent arthrodesis rates (9).
Chevron
The chevron arthrodesis popularized by Omer is believed to be more forgiving than transverse cuts (102,103). Cancellous bone area for fusion is improved, but the technique causes some digital shortening and is technically demanding. Cuts may be made with the apex of the chevron pointing either distally or proximally.
METHODS OF FIXATION
Many techniques to stabilize small-joint arthrodeses have been used, and multiple studies have described consistent success using different techniques (5,9,12,15,16,17,19,20,27,31,36,45,48,49 and 50,54,55,58,66,67,74,82,83,85,86,88,89,93,96,102,103,107). They differ with regard to the degree of difficulty of using the instrumentation, whether bone grafts are harvested from other surgical sites, and technical difficulty.
In a biomechanical study, Kovach et al. (54) compared crossed K-wires, tension band wiring, and an interosseous loop supplemented by a K-wire in a PIP arthrodesis model. Tension band wiring was found to be the strongest. In a
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comparison study of four methods of fixation for CMC arthrodesis using crossed K-wires, cerclage wiring, and cup and cone with single K-wire and tension band wiring, Stokel et al. (86) found that tension band wire and cerclage techniques provided the most stable construct. Bamberger et al. (6) have used the cup and cone method originally described by Carroll and Hill (19) with staple or K-wire fixation. They found a 42% delayed union/nonunion rate for the staple method compared to an 11% rate of delayed union for the K-wire group.
Crossed K-Wires and Tension Band
The crossed K-wire (15,19) (Fig. 72.3, Fig. 72.4) and tension band techniques (45,50,85,93) are the most frequently used of all fixation techniques in small-joint fusions (9,48). They provide stable fixation, are relatively uncomplicated technically, and may be used in conjunction with cup and cone, miter, or straight cut techniques. They allow easier adjustment of the arthrodesis site than many other techniques. Both techniques are excellent for the patient with rheumatoid arthritis, in whom inadequate bone stock may not allow screw techniques.
Figure 72.3. Metacarpophalangeal joint fusion with Kirschner wire fixation, lateral view.
Figure 72.4. Metacarpophalangeal joint fusion with Kirschner wire fixation, AP view.
  • Prepare both bone ends at the joint for arthrodesis and ensure good bone-to-bone contact. Then stabilize the arthrodesis by driving two crossed K-wires from distal to proximal across the joint. Pins driven from proximal to distal may distract the arthrodesis.
  • Drive one pin first, and then check the arthrodesis position by intraoperative radiographs or imaging on a fluoroscope. If the position is acceptable, drive the second pin and check the position once more. Position the pins to avoid prominence that might cause soft-tissue damage.
  • We do not leave K-wires exposed but cut them off below the level of the skin. Remove the pins when fusion is healed, which is usually in 4–6 weeks.
  • For the tension band technique, prepare the joint surfaces and position the joint.
  • Drill two K-wires parallel to each other, leaving a dorsal wire protruding from the proximal portion of the distal bone, 6 mm distal to the cut surface.
  • Drill a transverse hole through the proximal fragment and pass a malleable monofilament stainless steel wire of appropriate size through the hole.
  • Tightly coapt the fusion site and pass the monofilament wire in a figure-eight fashion dorsally. Pass it beneath and tighten it around the ends of the K-wires. The arthrodesis site will be compressed as the figure-eight wire is tightened.
  • Cut the pins as low as possible and contour them to fit closely to the bone dorsally. (See Chapter 11 for more details.)
When the fusion is healed, most pins and wires need to be removed as they are superficial and tender. Do not use tension band wire techniques at the DIP joint because of the possibility of injury to the germinal matrix of the nail.
Internal Fixation—Screw Techniques
Screw methods for fixing an arthrodesis provide stable rigid fixation, which is best used in young, active patients
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with high activity demands. Screw fixation usually permits early motion of the hand with a reduced risk of loss of fixation when compared to K-wire fixation. Many varieties of screws are currently available and all of them can be used to provide compression across the arthrodesis. Screw techniques require careful attention to technical detail.
Herbert Screw
The Herbert screw (Zimmer, Warsaw, IN) is a headless screw (see Chapter 11) originally used to fix fractures of the scaphoid (5,31,49,58).
  • To perform an arthrodesis on a PIP joint utilizing the Herbert screw, prepare the joint surfaces as previously described.
  • Drill a pilot hole with an 0.045 K-wire. Drill from the dorsal surface of the proximal phalanx into the medullary canal of the middle phalanx. We have found that starting the hole relatively proximal makes the dorsal cortical bridge larger, preventing fracture.
  • Use a small-diameter Herbert screw drill bit to enlarge the drill hole through its entire length, from proximal to distal. Avoid breaking the dorsal cortical bridge between the entry hole and the fusion site.
  • Enlarge the cortical opening with a small rongeur.
  • Using a large-diameter Herbert screw drill, overdrill the hole in the proximal phalanx. Then insert a Herbert screw tap through the arthrodesis site.
  • Use intraoperative radiography or fluoroscopy to help determine the size of the screw to be chosen. The screw should be at least 2 mm shorter than the measured length to allow the screw head to sink into the proximal phalanx and not cause soft-tissue irritation.
  • Place the Herbert screw of appropriate size. It is important to hold the arthrodesis site compressed in appropriate position as the screw is tightened.
Arthrodesis can also be performed on the DIP joint using Herbert screw fixation (Fig. 72.5, Fig. 72.6).
Figure 72.5. Intraoperative confirmation of distal interphalangeal joint arthrodesis with Herbert screw fixation.
Figure 72.6. Intraoperative confirmation of position, Herbert screw fixation, lateral view.
  • After preparing the joint surfaces, make a K-wire pilot hole drilling from proximal to distal through the center of the distal phalanx. The wire exits just under the hard nail, through the distal skin.
  • Make a transverse skin incision at this level and enlarge the pilot hole, using the small-diameter drill bit, from distal to proximal.
  • Position the arthrodesis site, and pass the small-diameter drill across the joint from distal to proximal.
  • Tap the drill hole from distal to proximal with the Herbert screw tap.
  • Use intraoperative fluoroscopic imaging to determine the length of the screw.
  • Place an appropriate-length Herbert screw from distal to proximal, countersinking the proximal threads of the Herbert screw deep enough to keep it from irritating the tip of the finger (84). Take care, as germinal matrix injuries can occur. Note that this technique at the DIP joint requires more extension than other techniques (Fig. 72.7, Fig. 72.8).
    Figure 72.7. Distal interphalangeal joint arthrodesis with Herbert screw fixation, AP view.
    Figure 72.8. Distal interphalangeal joint arthrodesis with Herbert screw fixation, lateral view.
Acutrak Screw
The Acutrak variable pitch conical screw (Acutrak, Acumed, Beaverton, OR) has been designed specifically
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for small-joint fusions. Techniques are as previously described for the Herbert screw.
AO Screw Fixation
Joint arthrodesis using the AO screw technique generally proceeds as described for the Herbert screw, with the following differences (88). The AO 2.7 mm screw is a standard screw with threads on one end and a head on the other; therefore, compression requires lag technique. Overdrill the proximal phalanx with a 2.7 mm drill bit to gain compression. Countersink the drill hole before you place the screw, which allows the screw to sit flush with the bone.
This screw can be inserted in a retrograde fashion for fusion of the DIP joint. In our experience, the AO screw head is too prominent, causing too much pain in the fingertip; therefore, we currently do not use it for DIP joint fusion.
Internal Fixation—Plate Fixation
Plate-and-screw fixation is the most stable construct available for performing an arthrodesis in the hand. Plating is an excellent technique when bone grafting is required. It requires significant soft-tissue stripping and is more complex, so it is used less commonly for a simple primary arthrodesis. Plate fixation is used more commonly for salvage of failed previous procedures.
  • After the joint ends have been exposed and prepared for arthrodesis, expose the dorsal aspects of the proximal and distal bone surfaces as necessary for plate application.
  • Once the bone ends are prepared and any bone graft has been selected, tailored, and placed, select a mini-semitubular plate that allows for at least two screws in the middle phalangeal shaft and two screws in the proximal phalangeal shaft. Generally, a four-hole plate will not bridge a significant defect, so a five- or six-hole plate may be required.
  • Contour the plate to fit over any bone graft dorsally.
  • Fix the plate with screws to the dorsal aspect of the distal bone first. Check the screw lengths using intraoperative fluoroscopy or radiographs.
  • Use the dynamic compression principle (Chapter 11) to apply compression between the bone ends and across any graft that is needed.
Because of the extensive surgery as well as the prominence of the plate and screws, removal and/or extensor tenolysis may be required as a second-stage procedure.
External Fixation
Compression arthrodesis is possible with mini-external fixators (12,83). Fusion rates are excellent but we feel that most external fixation devices are too bulky and limit the motion of other digits. The transverse wires and compression devices may cause scarring of the extensor mechanism. External fixators are most appropriate for fusions after severe articular surface bone and soft-tissue injuries complicated by joint infection and osteomyelitis (102). We do not recommend external fixation for uncomplicated phalangeal and MCP joint arthrodeses.
WOUND CLOSURE AND AFTERCARE
  • We prefer absorbable sutures for closure of the joint capsule and extensor tendon mechanism because the lack of joint motion after fusion takes tension off the tendon repair. Nonabsorbable sutures may cause patient discomfort after surgery by irritating the skin edges.
  • After closure of the deep soft tissues, injection of 0.5% bupivacaine may diminish postoperative discomfort.
  • Close the skin with interrupted nonabsorbable sutures.
  • Apply a well-padded bulky dressing, and splint the fused joints for comfort and to protect the arthrodesis. At 10–14 days, change the dressings and encourage motion at joints other than the fusion. Fashion an orthoplast splint to the fused joint and keep it in place until the fusion is radiographically solid. Protect thumb MCP and carpometacarpal fusions in thumb spica casts for 4–6 weeks.
PITFALLS AND COMPLICATIONS
Alt hough uncommon, complications in fusions of the small joints of the hand can be minimized by meticulous surgical technique (55,84,93). Management of complications begins with understanding the potential for them prior to surgery, and making the patient aware of them. Detect vascular compromise by carefully observing capillary refill in the operated digit after tourniquet deflation. Any impairment requires immediate intervention to prevent loss of the digit. Pin track infection can be minimized by keeping pins under the patient’s skin. Diminish wound
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problems by using straight longitudinal dorsal incisions, especially in patients with immunocompromised status, such as those with diabetes mellitus or connective tissue diseases. Prevent nonunion by establishing broad bone contact at the arthrodesis site and stable fixation.
Progression of arthritis in adjacent joints is a concern in any arthrodesis because stress is added across these joints. Carroll (16) found no evidence of STT arthritis after CMC joint fusion in patients less than 50 years old who were followed for 3–25 years. More recently, Bamberger et al. (6) had radiographs of their series of patients reviewed independently for progression of STT arthrosis after CMC arthrodesis. They found progression of STT arthritis in 2 of 12 patients but attributed this to error in technique. Guiral et al. (38) reported a rare complication of arteriovenous fistula with venous aneurysm after thumb carpometacarpal joint arthrodesis. This was treated by ligation and resection of the aneurysm. A painful scar from injury to the branches of the radial sensory nerve is avoided by careful technique. Problems with painful implants can be resolved by removal.
LIMITED WRIST FUSION
Limited wrist arthrodesis and intercarpal arthrodesis are useful for treating degenerative arthritis, carpal instability (57), fracture nonunion, ligament tears, Kienböck’s disease (60,70), osteonecrosis of the carpus, and congenital synchondrosis or partial fusion of various carpal intercarpal joints (4,7,13,24,34,37,51,53,75,91,95,97,98,99,100 and 101,106). A less desirable alternative in some cases is proximal row carpetomy (8,25,46,52).
Successful treatment using these surgical procedures is based on the biomechanical principle of load transfer from one side of the carpus to another. The intercarpal mobility that is preserved compensates for the motion lost to arthrodesis.
Currently, the most commonly performed limited wrist fusion procedures include STT fusion; scaphocapitate (SC) fusion; lunotriquetral (LT) fusion; and fusion of the capitate, hamate, lunate, and triquetrum, which is known as a four-bone fusion.
FUNCTIONAL WRIST MOTIONS
Recent studies have evaluated the range of motion needed for normal activities of daily living (ADL). Palmer et al. (73) showed that the range of motion of the wrist required for ADL is 5° of flexion, 30° of extension, 10° of radial deviation, and 15° of ulnar deviation. Brumfield and Champoux (14) showed that 10° of flexion and 35° of extension are required. Ryu et al. (80) showed that 40° of extension, 40° of flexion, and 40° of combined radial and ulnar deviation are needed to perform ADL.
INDICATIONS FOR SURGERY
DEGENERATIVE DISORDERS
The scaphoid is unique in that it spans both the proximal and the distal carpal rows. Because of its unusual anatomy, deformity of the wrist follows well-delineated patterns when the scaphoid or its ligamentous restraints are injured (see Chapter 41 and Chapter 42). One of these patterns, the scapholunate advanced collapse (SLAC) pattern of wrist arthritis, accounted for 57% of degenerative wrist arthritis when Watson and Ballet (98) reviewed 4,000 radiographs. These authors also reported primary triscaphe joint arthritis in 27% of these patients and a combination of both in 15% of patients. The primary disorder in the SLAC wrist is that of scapholunate dissociation secondary to scapholunate interosseous ligament rupture (3). This allows for unopposed volar flexion of the scaphoid and the dorsal intercalated segmental instability (DISI) pattern (26). Lateral radiographs may show the scapholunate angle to be increased beyond 60°, which is felt to be the upper limit of normal. On an anteroposterior (AP) radiograph, the scaphoid appears foreshortened, has a “cortical ring” sign and there is a scapholunate gap of greater than 3 mm.
The SLAC pattern of arthritis begins in its earliest stage, stage 1 arthritis, with destruction of the distal aspect of the radioscaphoid joint (2). This is caused by the incongruity between the scaphoid and the scaphoid facet of the radius when the scaphoid is extremely volar flexed. In stage 2, the entire radioscaphoid joint is arthritic. Stage 3 is characterized by further separation between the scaphoid and the lunate, allowing the capitate to migrate proximally. When this occurs, the SC and capitolunate joints become arthritic. Stage 4, in which the radiolunate joint becomes arthritic, is rarely seen because the spherical shape of the proximal lunate and the lunate fossa of the radius make incongruity unlikely except in the most severe cases.
A nonunion of a fracture of the scaphoid also leads to a predictable pattern of wrist arthritis when not treated. Because of its similarity to the SLAC pattern in both progression and treatment, it has been called the scaphoid nonunion advanced collapse (SNAC) pattern. In it, volar flexion of the distal pole of the scaphoid leads to radioscaphoid arthritis (101). The proximal pole, restrained by the scapholunate interosseous ligament, remains in normal alignment with the lunate. Given the dissociation between the proximal and distal rows as a result of the nonunion, a DISI pattern of deformity results. If left untreated, the
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wrist will undergo the same degenerative pattern seen in a SLAC wrist.
Treatment of these two similar disorders has been mainly proximal row carpectomy (46) or scaphoid excision (52) and lunate-capitate-hamate-triquetral (four-corner) arthrodesis (Fig. 72.9 and Fig. 72.10). Although it is not yet clear whether proximal row carpectomy or four-corner fusion provides better results (106) for stage 2 or 3 SLAC/SNAC disease, it is clear is that scaphoid excision and four-corner fusion are preferred to proximal row carpectomy when the capitate head is arthritic.
Figure 72.9. Capitohamate triquetrolunate intracarpal arthrodesis with spider plate fixation.
Figure 72.10. Capitohamate triquetrolunate intracarpal arthrodesis with spider plate fixation, lateral view.
With this procedure, pain relief and resolution of symptoms are predictable. In patients with stage 2 or 3 SLAC/SNAC disease, when strength is important and the patient’s activities do not require a full range of wrist motion, we perform scaphoid excision and four-corner fusion, as described later.
Another common problem in the wrist is isolated STT arthritis. The pain associated with this disorder can be surprisingly debilitating. The disability associated with STT arthritis can be best appreciated in activities that axially load the thumb (e.g., strong pinch, key turning). Watson et al. (99) attributed rotatory subluxation of the scaphoid as a possible cause of isolated STT arthritis. They noted early degenerative changes in these joints when performing rotary subluxation of the scaphoid (RSS surgery). For isolated STT arthritis, STT arthrodesis has been found to give good function and excellent pain relief and is preferred by other authors (53,97).
A less common but equally disabling degenerative pattern of arthritis in the wrist occurs between the lunate and the triquetrum (24,42,51). This pattern of arthritis is most probably a result of a chronic lunotriquetal ligament tear that has not healed. Patients typically have the radiographic findings associated with volar intercalated segmental instability (VISI). The scapholunate angle on a lateral radiograph is less than 30°, the lower limit of normal. This indicates that the ligamentous complex between the lunate and the triquetrum is disrupted, allowing the lunate to volar-flex and align with the scaphoid. Another cause of isolated LT arthritis is incomplete carpal coalition of the lunate and triquetrum (1).
Degenerative wrist disease evolves when scaphoid nonunion is left untreated, and in the SLAC wrist deformity. Watson and Weinzweig (101) described the use of STT arthrodeses to manage scaphoid nonunion for three specific indications: scaphoid fractures with a very small proximal fragment, a distal scaphoid nonunion causing malalignment of the triscaphe joint, and scaphoid fracture in association with scapholunate dissociation. With small scaphoid proximal fragments, Watson prefers a dorsal approach with bone grafting of the nonunion, with a simultaneous triscaphe arthrodesis. STT arthrodesis is used in distal scaphoid nonunions to improve alignment in the STT joint. Scapholunate dissociation may be treated by intercarpal arthrodesis when it is associated with scaphoid fracture.
CARPAL INSTABILITY
A detailed description of carpal instability can be found in Chapter 41. Instabilities result from a wide range of injuries that are either static or dynamic (24,65). Static instabilities have malalignments seen on standard radiographs. Dynamic instabilities may appear normally aligned on standard radiographs but are often exhibited on stress views or other special projections. Acute injuries (up to 1 week old) have the maximum potential to go on to primary healing of the ligaments. Subacute injuries (1–6 weeks old) still can heal and do not display fixed deformity or arthrosis. Chronic injuries older than 6 weeks have the least potential for healing, may have fixed deformities or
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arthrosis, and often require surgical repair and reconstruction. It is apparent that early detection is most important. The position of the lunate as seen on lateral radiographs is one of the key elements used to determine loss of normal carpal alignment. The terms dorsal intercalated segmental instability and volar intercalated segmental instability describe the malaligned dorsal or volar tilted lunate of unstable wrists (61). Although many instability classifications have been proposed, none have gained universal acceptance, which underscores the complexities of these injuries and the lack of our present comprehension of this subject.
The effects of intercarpal arthrodesis on wrist kinematics is not well understood. When choosing the surgical procedure, consider the amount of wrist motion that will remain and to what extent compensatory increases in wrist motion will occur over time. Although the proximal and distal rows function separately, an intercarpal arthrodesis that links these rows will have long-term effects on wrist motion and on radiocarpal and ulnocarpal loading that could lead to degenerative arthritis in the long term. Gellman et al. (35) showed that fusion within a carpal row has minimal effect on wrist motion in all planes. Their study demonstrated that two thirds of flexion occurs at the radiocarpal joint and one third occurs at the mid-carpal joint. It also showed that capitolunate fusion caused the greatest loss of motion in a flexion/extension arc, with STT fusion causing the greatest loss of motion in the radioulnar plane.
Garcia-Elias et al. (34) studied the effects of intercarpal arthrodeses on wrist range of motion. They showed that STT fusions had a greater loss of flexion than SC fusion, which resulted in a greater loss of extension and radial deviation. Shear stress was noted to be increased at the radiolunate joint. Viegas et al. (95) reported that STT and SC fusions decrease axial load through the radioscaphoid fossa, while scapholunocapitate and capitolunate fusions distribute load through both the radioscaphoid and radiolunate fossae.
SURGICAL TECHNIQUES
PRINCIPLES OF INTERCARPAL ARTHRODESES
Watson and Weinzweig (101) have outlined three major principles that apply to limited wrist arthrodesis:
  • Unaffected joints must be left unfused.
  • Normal external dimensions of carpal bones included in the arthrodesis must be preserved.
  • Bone fixation must include only those bones that are involved in the arthrodesis.
Adherence to these principles is important. STT (triscaphe) fusion results in a single bony unit that preserves the external dimensions of these three carpal bones. Current indications for STT fusion are STT arthrosis, Kienböck’s disease, and carpal instability, including static or dynamic rotary subluxation of the scaphoid.
WATSON AND ASHMEAD’S TECHNIQUE FOR STT FUSION
  • Make a dorsal transverse incision on the wrist just distal to the radial styloid (10).
  • Expose the radial styloid through an incision in the capsule overlying the radial styloid and scaphoid junction.
  • Remove the distal 5 mm of the styloid with a rongeur, sloping in a palmar direction from distal to proximal.
  • Make a transverse dorsal capsular incision and evaluate the radioscaphoid interval.
  • Watson and Ashmead (97) recommend performing a SLAC wrist reconstruction rather than a triscaphe arthrodesis if there is any articular cartilage damage. It is critical in an STT fusion to have normal articular cartilage between the distal radius and the proximal scaphoid.
  • Remove the articular surfaces between the scaphoid, trapezium, and trapezoid with a small rongeur, taking only the proximal half of the trapezium and trapezoid articulations. Remove the hard subchondral bone down to softer cancellous surfaces.
  • Remove the dorsal cortex of the trapezium and trapezoid to provide a broader surface area for bone graft.
  • Use the distal radius as a source of cancellous bone for grafting (71). To harvest the graft, make a second, transverse incision 3 cm proximal to the radial styloid, extending from Lister’s tubercle to just palmar to the first dorsal compartment. A flat surface on the radius can always be identified between the first and second extensor compartments, and a constant periosteal artery is seen in this area.
  • Incise the periosteum and make a cortical window. Remove cancellous bone from the distal radius and replace the cortical window after harvesting the graft.
  • The most important part of this procedure is the reduction of the scaphoid. Watson and Ashmead (97) do this by placing a 5 mm spacer, which is usually the handle of a small bone hook, into the scaphotrapezoid space to maintain the original external dimensions of the triscaphe joint and manipulate the scaphoid into proper position. Then drive one or two K-wires from the trapezium and trapezoid into the scaphoid, avoiding impingement of the radioscaphoid joint.
  • Remove the spacer and pass a second K-wire on the ulnar side of fusion construct (Fig. 72.11).
    Figure 72.11. Capitohamate triquetrolunate arthrodesis with Kirschner wire fixation, AP view.
  • Pin the scaphoid to lie at approximately 55° of palmar flexion relative to the long axis of the radius when seen on a lateral radiograph. When the wrist is placed in full
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    radial deviation and 45° of dorsiflexion, the scaphoid tuberosity should be reduced.
  • Densely pack cancellous bone into the spaces between the trapezium, the trapezoid, and the scaphoid.
  • Cut the K-wires short and leave them under the skin.
  • Close only the skin and subcutaneous tissues.
Postoperative Care
Apply a bulky noncompressive dressing, incorporating a long-arm plaster splint to place the hand in a functional position, with the wrist in slight extension and radial deviation, the forearm in neutral position, and the elbow at 90° of flexion. Three to 5 days later, change this and apply a long-arm thumb spica cast. At 4 weeks, exchange the cast for a short-arm thumb spica cast. At 6 weeks after surgery, if there is radiographic evidence of healing, remove the K-wires. Begin range-of-motion exercises once fusion is ensured.
SCAPHOCAPITATE FUSION
Indications for scaphocapitate (SC) fusion include rotary subluxation of the scaphoid and scaphoid instability, resistant scaphoid nonunion, and Kienböck’s disease.
  • Make a longitudinal skin incision of sufficient length over the third dorsal compartment, and open the retinaculum.
  • Free the EPL tendon proximally and distally, and transpose it radially. This allows retraction of the radial wrist extensors, the EPL, and the digital extensors.
  • Make a longitudinal incision in the capsule and develop radial and ulnar flaps.
  • Inspect the proximal scaphoid and distal radial articular cartilage as for the STT arthrodesis. If there is any indication of degenerative arthritis in the radiocarpal joint, do a SLAC wrist reconstruction instead.
  • Remove the articular surface between the scaphoid and the capitate, using rongeurs and curets.
  • Harvest a bone graft from the radius, as described previously for the STT fusion.
  • After aligning the scaphoid, drive two 0.045 K-wires from the scaphoid into the capitate.
  • Pack bone graft into the scaphoid–capitate gap. Cut off the K-wires under the skin, and close the capsule with absorbable suture. Close the third dorsal compartment with absorbable suture.
  • Close the skin and subcutaneous fat with nonabsorbable suture and inject 0.5% bupivacaine for postoperative pain control.
  • Postoperative immobilization is identical to that of the STT fusion, as is the postoperative management.
SLAC RECONSTRUCTION AND HAMATE-CAPITATE-LUNATE-TRIQUETRAL FUSION
A SLAC wrist reconstruction along with excision of the scaphoid is an excellent method to treat radioscaphoid degenerative arthritis and chronic nonunion of the scaphoid, as well as advanced destruction from scapholunate dissociation or idiopathic avascular necrosis of the scaphoid.
  • Make a longitudinal incision dorsally, over the third and fourth dorsal compartments.
  • Open the third dorsal compartment, and transpose the EPL tendon radially. Then retract the radial wrist extensors radially and the digital extensors ulnarly.
  • Then open the capsule with a longitudinal incision and elevate the capsule to create radial and ulnar flaps.
  • Excise the scaphoid.
  • Prepare the articular surfaces between the capitate, lunate, triquetrum, and hamate by removing the articular cartilage and subchondral bone between them.
  • Harvest cancellous bone proximally from the distal radius, as previously described.
  • Anatomic alignment of the four carpal bones is important to provide an excellent outcome. The position of the lunate is critical.
  • Flex the lunate from its extended position into a neutral position, generally by using a “joystick,” such as a 0.045 K-wire inserted into the lunate.
  • Fix the remaining four carpal bones. Confirm proper position with a radiograph. K-wires (Fig. 72.11), Herbert and other types of screws, and, recently, new plate–screw systems have been used to provide fixation and allow early mobilization (Fig. 72.9, Fig. 72.10). After
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    fixation, pack the intercarpal spaces with cancellous bone.
  • Cut off any K-wires beneath the patient’s skin and close the capsule with absorbable suture. Close the skin with nonabsorbable suture, and inject the operative site with 0.5% bupivacaine.
Postoperative Care
Apply a short-arm thumb spica splint, and exchange it 5–7 days later for a short-arm thumb spica cast. Generally, leave wires in for 6 weeks. At that time, remove the K-wires if early union is seen.
LUNOTRIQUETRAL ARTHRODESIS
Lunotriquetral (LT) arthrodesis is indicated in patients with LT instability, LT arthrosis, or LT ligament disruption.
  • Make a longitudinal incision between the fifth and sixth dorsal compartments.
  • Protect the dorsal sensory branch of the ulnar nerve throughout the procedure.
  • Open the joint capsule between the lunate and the triquetrum.
  • Remove the articular cartilage between these two bones down to subchondral bone.
  • Place three 0.045 K-wires or compression screws across this joint.
  • Pack the gap between the two bones with bone graft harvested from the radius as described previously.
  • Close the capsule with absorbable sutures and the skin with nonabsorbable sutures.
Postoperative Care
Apply a padded long-arm splint and keep it in place for 5–7 days, then exchange it for a long-arm cast. Keep this in place for 6 weeks to allow for adequate healing, as evidenced clinically and radiographically. Then remove pins and use a short-arm splint for 4–6 weeks.
PITFALLS AND COMPLICATIONS
Complications of limited wrist arthrodeses may be split into two categories: intraoperative complications and problems with long-term outcomes (13,53,106). Major complications from STT arthrodesis include radiocarpal arthrosis, trapeziometacarpal arthrosis, nonunion, osteomyelitis, and radial styloid scaphoid impingement (79). This last complication has been diminished by radial styloidectomy at the time of surgery. Inadequate reduction of the scaphoid in this procedure leads to a predictable progression of radiocarpal arthritis. The proximal pole of the scaphoid must be reduced anatomically into the scaphoid fossa of the radius, and the radioscaphoid angle must be approximately 45° to 55°.
Similar complications have been reported for SC arthrodesis. Long-term follow-up has shown a greater loss of wrist flexion with the latter procedure. Relatively few complications have been reported with the SLAC wrist reconstruction or four-bone arthrodesis. Nonunion has been rare, and the development of radiolunate arthritis and impingement between the fusion mass and the distal radius have been reported. The most common complication of LT joint arthrodesis is nonunion, with a reported incidence of 10% to 50% (13,52,53,91,100,106).
RADIOCARPAL OR WRIST ARTHRODESIS
Radiocarpal or wrist arthrodesis involves fusion of the radiocarpal and mid-carpal joints, including the radiolunate, radioscaphoid, and radiocapitate joints. It is one of the oldest, most common, longest-used, and most successful reconstruction procedures for the wrist (39,40 and 41,44,59). It predictably relieves pain, but it does eliminate all radiocarpal motion.
INDICATIONS FOR SURGERY
Currently, the most common indication for total wrist arthrodesis is posttraumatic degenerative arthritis of the radiocarpal and midcarpal joints (41). This includes chronic carpal dissociations as well as complex intracarpal and distal radius intraarticular fractures. Other indications for arthrodesis include the following:
  • Chronic infection unresponsive to limited surgical debridement (29,30)
  • Paralysis about the wrist and hand (arthrodesis provides the stability required for tendon transfers about the thumb and digits) (87)
  • Rheumatoid arthritis and other inflammatory disorders involving the radiocarpal joint (18,28,63,64)
  • Limited arthrodeses that have not provided stability or pain relief
  • Loss of soft tissue and bone as a result of severe trauma or tumor resection
Spastic paralysis of the wrist from cerebral palsy, strokes, or polio can lead to severe disfigurement of the
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extremity and loss of hand function. Stabilization of the wrist makes the flexor and extensors of the wrist available as transfers to restore power and function to the fingers. Pomerance and Keenan (76) demonstrated that by performing total wrist fusion, tendon transfers, and muscle releases in a single staged procedure, they were able to correct the severe contractures of the hand and wrist with resolution of the preoperative hygiene problems. (See Chapter 66, Chapter 67 and Chapter 68 for more details.)
Most patients who are considered for arthrodesis have undergone failed attempts at both conservative and surgical treatments. Hastings et al. (41) reported that 71% of the 112 wrists that underwent arthrodeses for posttraumatic arthritis had undergone 137 prior surgical procedures, for an average of 2.3 procedures each. Field et al. (32) found a mean of three operations (mostly limited carpal fusions) performed on the wrist in their 20 patients undergoing arthrodesis for posttraumatic conditions. By the time many of these patients present for arthrodesis, they have so much pain in the wrist that they have little or no motion remaining. For these patients, a total wrist fusion improves stability and function, decreases deformity, and relieves pain.
BIOMECHANICS
The usual recommendation is to fuse the wrist in dorsiflexion from 0° to 30° to preserve grip and pinch strength. Colonna (23) described power grip as maximal with the wrist in slight extension and slight ulnar deviation. Kraft and Detels (56) simulated wrist arthrodesis in varying degrees of flexion and extension in 20 normal volunteers by immobilizing them in leather gauntlets. This study showed that from 15° of flexion to 30° of extension, the grip strength was equal in all positions except for 15° flexion, where it was decreased. Their overall recommendation was to avoid fusing the wrist in flexion. They recommended placement of the wrist in palmar flexion only when there is bilateral involvement and one wrist is placed in extension, the other in flexion to improve independent feeding and perineal care.
Hastings et al. (41) found that function after radiocarpal fusion was comparable to that for limited wrist fusion. Whereas Jebsen et al. (47) and Purdue (90) found hand function to be poor based on testing, Field et al. (32) found that all patients were satisfied and would have had the procedure sooner. Weiss et al. (105) found that most patients functioned well after wrist arthrodesis for posttraumatic conditions and that the most difficult tasks were perineal care and manipulating the hand in tight spaces. Rayan et al. (78) reviewed the function of nine rheumatoid arthritis patients and found that even among those who underwent bilateral radiocarpal arthrodesis, seven of nine had improvement of subjective function, two of nine remained the same, and no patient was made worse.
Vicar and Burton (94) compared the results of arthroplasty versus radiocarpal arthrodesis in rheumatoid arthritis patients. They found that the arthrodesis group had overall 97% good results compared to 75% good results in the arthroplasty group. The arthrodesis group had an 18% complication rate, while the arthroplasty group had a 25% complication rate, 4 of 37 requiring revision, at an average follow-up of 51 months.
Radiocarpal arthrodesis seems to be the treatment of choice for the most severe wrist deformities, but efforts to perfect wrist arthroplasty and motion-preserving operations continue. While it is likely true that most patients would prefer a motion-sparing procedure to radiocarpal arthrodesis, function after complete wrist fusion is surprisingly good and therefore this remains the gold standard to which all other procedures should be compared. With the right indications, radiocarpal arthrodesis can salvage function for an otherwise debilitated patient.
Position for radiocarpal arthrodesis is directly related to the final function desired, and although a wrist fused in a poor position may be pain free, function suffers. The ideal position for radiocarpal arthrodesis is controversial. Several studies recommended fusion in 20° to 30° of extension (11,18,21,22,32,41,44,59,62,64,68,70,81,104) and Clayton and Ferlic (21) recommended neutral position. Although the ideal position for radiocarpal fusion likely will continue to be debated, functional outcome studies show that a position in 0° to 10° of extension and 0° to 10° of ulnar deviation seems to give the best results.
The methods advocated for radiocarpal arthrodesis are quite numerous. Techniques utilizing a distal radius sliding graft (22), an AO plate (101), and intramedullary pins or rods (64,68) have been described.
SURGICAL CONSIDERATIONS
Evaluate patients medically and understand the medical diagnosis underlying the wrist deformity in patients with systemic disease before performing surgery. This is most important in evaluating patients with rheumatoid arthritis.
Rheumatoid arthritis is a systemic disease affecting many joints in the body. These patients often have a “Z-collapsed” deformity, where deformity in a proximal joint provokes a reciprocal deformity at a distal joint (70). Surgical procedures performed on any of these joints affect the more distal or proximal joints. In patients with rheumatoid arthritis, keep procedures minimal and simple. Wrist fusion using a Steinmann pin for intramedullary fixation is better than using a dorsal plate, as it is less likely to cause problems with the skin and extensor tendons. Stability is adequate, immobilization is shortened, an iliac
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crest graft is usually not required, and splinting and partial weight bearing early is possible. Millender and Nalebuff (68) reported that patients were able to walk with platform crutches 1 week after surgery using this technique. Another advantage of this procedure is that it can be performed rapidly enough to allow other surgical procedures to be performed concomitantly, as is necessary in many patients with severe rheumatoid arthritis (69). (See Chapter 70 for more details on treatment of the rheumatoid hand.)
Patients with posttraumatic arthritis place heavier loads and higher demands on their hands and wrists than do patients with rheumatoid arthritis. Rigid internal fixation is crucial. Recent studies have shown that plate fixation with the application of local bone graft provides reliable fusion and early rehabilitation (11,104).
SURGICAL TECHNIQUES
STEINMANN PIN TECHNIQUE
Perform surgery with preoperative intravenous antibiotics and axillary block or general anesthesia. All patients with connective tissue diseases or in whom there is concern of cervical spine instability are prescreened with cervical spine radiographs. Perform all surgery under tourniquet control, through a dorsal longitudinal skin approach to the extensor retinaculum.
We prefer a modification of techniques originally proposed by Clayton and Ferlic (21), Mannerfelt and Malmsten (64), and Millender and Nalebuff (68), as follows.
  • Use a longitudinal skin incision just ulnar to Lister’s tubercle.
  • Make a longitudinal incision through the fascia of the third dorsal compartment, and transpose the EPL tendon.
  • Incise the floor of the third compartment and extend it distally to the base of the third metacarpal, staying ulnar to the extensor carpi radialis brevis (ECRB) tendons.
  • Using subperiosteal dissection, raise medial and lateral flaps to expose the entire distal radius, ulna, and carpus.
  • We resect the posterior interosseous nerve in the floor of the fourth compartment to provide lasting pain relief. Because of the commonly associated disease of the distal radioulnar joint (DRUJ) in patients with rheumatoid arthritis, we prefer to perform a Darrach resection of the distal ulna by transecting the distal ulnar shaft just proximal to the ulnar head, using an oscillating saw (see Chapter 43).
  • Use a subperiosteal approach to excise the entire distal ulna. Preserve the ulnar head for use as autogenous bone graft.
  • Using a small rongeur, resect the remaining radiocarpal and intercarpal articular surfaces, including the third CMC and intercarpal joints, until you expose cancellous bone. Use the harvested distal ulna to fill the defects between the intercarpal joints. If more bone graft is needed, use a curet to harvest any needed bone from the distal radius through the base of Lister’s tubercle.
  • Insert a 3.2 or 3.6 mm Steinmann pin either down the medullary canal of the third metacarpal shaft or between the second and third metacarpal bases for more ulnar deviation, and bring it out distally through the skin.
  • Reduce the wrist into final position, and slip a drill guide over the distal end of the pin. Slide a similar-size pin into the guide and tap the pin across the wrist into the radius in a retrograde fashion. Bury the pin distally under the skin.
  • Confirm adequate pin position with intraoperative radiographs or insert the pin under fluoroscopic control.
  • Transpose approximately one third to one half of the extensor retinaculum palmar to the extensor tendons, and suture it into place with absorbable sutures. Place a suction drain deep into the wound and bring it out distally for ease of removal the following day. Place subcutaneous sutures and then close the skin with nonabsorbable sutures in an interrupted fashion.
Postoperative Care
Apply a palmar plaster splint and dressing to control rotation. Remove the drain in 24 hours. After 1 week, remove the dressing and inspect the wound. Generally leave sutures in for 2 weeks and keep the patient in a splint or cast until their removal. At 2 weeks postoperatively, remove the sutures and place the patient into a short-arm cast for an additional 2–4 weeks, or until clinical and radiographic union is achieved. Encourage the patient to mobilize his or her fingers as much as possible until the cast is removed. At that time, evaluate the patient and treat any remaining stiffness with aggressive hand therapy.
AO WRIST FUSION PLATE
When performing radiocarpal arthrodesis for indications other than rheumatoid arthritis, we prefer to use the AO method of plate fixation popularized by Hastings (39) and others (81) (Fig. 72.12 and Fig. 72.13). Most commonly, the indication for this type of arthrodesis is posttraumatic arthritis of the wrist or failed wrist arthroplasty.
Figure 72.12. Radiocarpal arthrodesis using wrist fusion plate, AP view.
Figure 72.13. Radiocarpal arthrodesis using wrist fusion plate, lateral view.
  • Make a midline dorsal longitudinal skin incision.
  • Open the third dorsal compartment and transpose the EPL tendon. Expose the entire carpus and distal radius, as well as the base of the third metacarpal subperiosteally. Do not enter the DRUJ unless there is concomitant disease that is being treated surgically. The best
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    way to avoid the problem of DRUJ instability after arthrodesis is to keep the volar and dorsal radioulnar ligament complex intact.
  • Decorticate the dorsal 50% of the joint surfaces of the radioscapholunate, the radioscaphocapitate, the scapholunate, the lunocapitate, and the capitate, and the third metacarpal base until you expose cancellous bone.
  • Arthrodesis of the remaining joints of the carpus and the second carpometacarpal joint can be performed, but we add these joints only if concomitant arthrosis exists. Keeping the volar 50% of the articular surface intact maintains alignment of the carpus better than if the entire joint is taken.
  • Harvest cancellous bone graft from the distal radius by removing Lister’s tubercle and widening the cortical defect with a curet.
  • Contour the dorsal surfaces of the distal radius, lunate, capitate, and third metacarpal base with an osteotome so that the plate fits against the bone without gaps or defects.
  • Before fixing the plate to the wrist, pack cancellous bone graft between the joint surfaces to be fused. Apply the plate (we prefer the precontoured AO wrist fusion plate, which provides 10° to 15° of wrist extension) first to the third metacarpal with at least three 2.7 mm cortical screws. Stabilize the distal radius with at least three (usually four) 3.5 mm cortical screws. Then use a cancellous screw to affix the plate to the carpus (usually the capitate).
  • Ensure that the position of the hardware is adequate with intraoperative radiographs or fluoroscopy, and make changes as necessary.
  • Close the wound by transposing one third to one half of the extensor retinaculum volar to the extensor tendons over the plate.
  • Place a suction drain deep into the wound and bring it out distally for removal the next day.
  • Close the skin with interrupted horizontal mattress sutures of 4-0 nylon.
Postoperative Care
Apply a sterile bandage and a short-arm volar splint. After 1 week, remove the bandage and splint; inspect the wound and remove the sutures if it is adequately healed. Apply a custom-molded plastizote splint and begin a controlled-motion hand therapy protocol. Do not permit active exercises
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against resistance until clinical and radiographic union is achieved, usually in 6–10 weeks.
PITFALLS AND COMPLICATIONS
Numerous authors using different surgical techniques have reported complications of radiocarpal arthrodesis. Clendenin and Green (22) divided these into major complications (requiring revision surgery or prolonged hospitalization) and minor (when morbidity is prolonged but resolves without further hospitalization). Major complications include nonunion, wound infection, painful neuromas, fracture of a previously healed fusion, iliac crest bone graft site complications, acute carpal tunnel syndrome, plate failure, DRUJ and ulnocarpal impingement (33,77,92), and chronic pain syndromes. Minor complications include postoperative pain caused by tight dressings, sensory neurapraxias, minor skin irritations, and necrosis. Hastings (39) noted that major complications are less common in internal fixation with a wrist fusion plate than in other surgical methods. Bone graft donor site morbidity can be diminished by using local bone graft for radiocarpal arthrodesis.
Overall rates of nonunion range from 5% to 20% (22,39), whereas rates of nonunion with the AO wrist fusion plate technique have been reported to be from 0% to 2% (32,41,104).
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Each reference is categorized according to the following scheme: *, classic article; #, review article; !, basic research article; and +, clinical results/outcome study.
+ 1. Alberts KA, Engkvist O. Arthrodesis of the First Metacarpal Joint: 33 Cases of Arthrosis. Acta Orthop Scand 1989;60:258
# 2. Ashmead D, Watson HK. SLAC Wrist Reconstruction. In: Gelberman R, ed. The Wrist. New York: Raven Press, 1994.
+ 3. Ashmead D, Watson HK, Damon C, et al. Scapholunate Advanced Collapse Wrist Salvage. J Hand Surg [Am] 1994;19:741.
+ 4. Ashmead D, Watson HK, Weinzweigh J, Zeppieri J. One Thousand Intercarpal Arthrodeses. J Hand Surg [Br] 1996;21:10.
+ 5. Ayres JR, Goldstrohm GL, Miller GJ, Dell PC. Proximal Interphalangeal Joint Arthrodesis with the Herbert Screw. J Hand Surg [Am] 1988;13A:600.
+ 6. Bamberger HB, Stern PJ, Kiefhabert TR, et al. Trapeziometacarpal Joint Arthrodesis: A Functional Evaluation. J Hand Surg [Am] 1992;17:605.
+ 7. Bednar JM, Osterman AL. Carpal Instability: Evaluation and Treatment. J Am Acad Orthop Surg 1994;19A:1016.
+ 8. Begley BW, Engber WD. Proximal Row Carpectomy in Advanced Kienböck’s Disease. J Hand Surg [Am] 1994;19:1016.
+ 9. Bishop AT. Small Joint Arthrodesis. Hand Clin 1993;9:683.
+ 10. Biyani A, Ebraheim NA, Lu J, Yeasting RA. A Modified Dorsal Approach to the Wrist for Arthrodesis of the Non-Rheumatoid Wrist. An Anatomical Study. J Hand Surg [Br] 1996;21:434.
+ 11. Bolano LE, Green DP. Wrist Arthrodesis in Post-Traumatic Arthritis: A Comparison of Two Methods. J Hand Surg [Am] 1993;18:786.
+ 12. Braun RM, Rhoades CE. Dynamic Compression for Small Joint Arthrodesis. J Hand Surg [Am] 1985;10:340.
+ 13. Brown RE, Erdmann D. Complications of 50 Consecutive Limited Wrist Fusions by a Single Surgeon. Ann Plastic Surg 1995;35:46.
! 14. Brumfield RH, Champoux JA. A Biomechanical Study of Normal Functional Wrist Motion. Clin Orthop 1984;187:23.
+ 15. Burton RI, Margles SW, Lunseth PA. Small Joint Arthrodesis in the Hand. J Hand Surg [Am] 1986;11:678.
+ 16. Carroll RE. Arthrodesis of the Carpometacarpal Joint of the Thumb. A Review of Patients with a Long Postoperative Period. Clin Orthop 1987;220:106.
+ 17. Carroll RE, Carlson E. Diagnosis and Treatment of Injury to the Second and Third Carpometacarpal Joints. J Hand Surg [Am] 1989;14:102.
+ 18. Carroll RE, Dick HM. Arthrodesis of the Wrist for Rheumatoid Arthritis. J Bone Joint Surg Am 1971;53:1365.
+ 19. Carroll RE, Hill NA. Small Joint Arthrodesis in Hand Reconstruction. J Bone Joint Surg Am 1969;51:1219.
+ 20. Chamay A, Piaget-Morerod F. Arthrodesis of the Trapeziometacarpal Joint. J Hand Surg [Br] 1994;19:489.
+ 21. Clayton ML, Ferlic DC. Arthrodesis of the Arthritic Wrist. Clin Orthop 1984;187:89.
+ 22. Clendenin MB, Green DP. Arthrodesis of the Wrist—Complications and Their Management. J Hand Surg 1981;6:253.
* 23. Colonna PC. A Method of Fusion of the Wrist. South Med J 1944;37:1.
# 24. Cooney WP III, Linscheid RL, Dobyns JH. Carpal Instability: Treatment of Ligament Injuries of the Wrist. Instr Course Lect 1992;41:33.
+ 25. Culp RW, McGuigan FX, Turner MA, et al. Proximal Row Carpectomy: A Multicenter Study. J Hand Surg [Am] 1993;18:19.
# 26. Dobyns JH, Linscheid RL, Chao EY, et al. Traumatic Instability of the Wrist. Instr Course Lect 1975;24:182.
+ 27. Doyle JR. Sliding Bone Graft Technique for Arthrodesis of the Trapeziometacarpal Joint of the Thumb. J Hand Surg [Am] 1991;16:363.
+ 28. Dray GJ, Millender LH, Nalebuff EA, Phillips C. The Surgical Treatment of Hand Deformities in Systemic Lupus Erythematosus. J Hand Surg 1981;6:339.
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+ 28a. Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligamentous Reconstruction for the Painful Thumb Carpometacarpal Joint: A Long-term Assessment. J Hand Surg [Am] 1984,9:692.
* 29. Ely LW. Study of Joint Tuberculosis. Surg Gynecol Obstet 1910;10:561.
* 30. Ely LW. An Operation for Tuberculosis of the Wrist. JAMA 1920;75:1707.
+ 31. Faithfull DK, Herbert TJ. Small Joint Fusions of the Hand Using the Herbert Bone Screw. J Hand Surg [Br] 1984;9:167.
+ 32. Field J, Herbert TJ, Prosser R. Total Wrist Fusion. A Functional Assessment. J Hand Surg [Br] 1996;21B:429.
+ 33. Friedman S, Palmar A. The Ulnar Impaction Syndrome. Hand Clin 1991;7:295.
! 34. Garcia-Elias M, Cooney WP, An KN, et al. Wrist Kinematics after Limited Intercarpal Arthrodesis. J Hand Surg [Am] 1989;14:791.
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